Healthcare Safety Technician Certificate Request

Healthcare Safety Technician Certificate Healthcare Safety Technician Certificate
Application Form

  • To earn the Healthcare Safety Technician Certificate, the individual will have to successfully complete seven required courses.
  • At least five of the courses, including the final two, must be completed through the CSUDH OTIEC.
  • All courses must be completed within a 5 year period. The official “certificate enrollment date” is the first day of the first CSUDH OTIEC course the participant wishes to count towards the certificate of completion.
  • Courses taken through other official OSHA Training Institute Education Centers can be used to fulfill up to two courses required for the Healthcare Safety Technician Certificate.

Student Information


[Name as it should appear on the printed Certificate]

[Include Street Address, City, State and Zip Code]

Certificate Courses (check all that apply)

Required (7 Courses)

The following courses have been approved through curriculum process.








Student Signature